Although there is a cumulative evidence for the inflammation pathophysiology in schizophrenia, it has not been conclusively proven yet. One reason for this is the lack of studies that have controlled for major confounding factors such as obesity, smoking, antipsychotic use, and stress. The studies in which the major confounding factors were controlled were done in subjects in acute relapse and in treatment-resistant schizophrenia. To date, no studies have been done in stable outpatients with schizophrenia controlling for major confounding factors. Data on cerebrospinal fluid cytokines in large sample independent of confounding factors are also lacking. The efficacy signal from anti-inflammatory medications in schizophrenia has been modest. In this study, the inconsistent and nonvalidated cytokine findings independent of the confounding factors are discussed.

Background: A few studies have examined the factors associated with schizophrenia patients remaining untreated in India. Materials and Methods: We identified 184 schizophrenia patients in a rural community, offered the treatment with antipsychotics and followed them up in their Primary Health Centers for 1-year. Twenty-nine (15.8%) patients remained untreated at both the baseline and 1-year follow-up despite our best attempts to keep them under the treatment umbrella. They were interviewed in detail regarding the reasons for remaining untreated. This group was compared with another group of patients (n = 69) who had stopped the treatment at baseline but were successfully brought under the treatment umbrella throughout the 1-year follow-up period. Results: The reasons for remaining untreated were (n; %): (a) Unsatisfactory improvement with previous treatment attempts (19; 65.5%), (b) poor bond between the patients and the families (6; 20.7%), (c) active symptoms not allowing any treatment efforts from the family members (6; 20.7%), (d) magico-religious beliefs about the illness and its treatment (4; 13.8%), (e) poor social support (3; 10.3%), (f) adverse effects of the medications (2; 6.9%), and (g) perception of recovery and cure (1; 3.4%). For many patients, a constellation of these reasons was responsible for them remaining untreated. In contrast, the common reasons for those who restarted medications to have stopped the treatment at some time were the lack of awareness, the need to continue medications (47; 68.1%), and the financial constraints (28; 40.6%). Conclusion: The predominant reason for schizophrenia patients not remaining on the treatment in this rural community was the families' lack of faith in antipsychotic treatment. Provision of comprehensive treatment package including medical, psychosocial and rehabilitative services, and sensitizing the community about benefits of the treatment may help in ensuring that all patients with psychosis receive the best care.

Need for validation of fagerstrom test for nicotine dependence in Indian context: Implications for nicotine replacement therapy

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Manoj Kumar Sharma, Priyamvada SharmaDOI:10.4103/0253-7176.178768

Background: Variety of smokeable and chewable tobacco products with diverse nicotine content are used in India. Nicotine quantity in tobacco products has a direct bearing on developing tobacco dependence. The present work used this information to derive scores on the Fagerstrom test for nicotine dependence (FTND). It was used to determine the dosing of nicotine replacement treatment (NRT). Materials and Methods: Nicotine score quantitation was taken from the previous study. This data was applied to FTND to determine the relationship of nicotine content to the potential degree of dependence. Results: Application of nicotine quantitation to FTND in a hypothetical experiment significantly altered the scores from medium to high depending on the brand the used. Conclusion: Application of qunatitation of nicotine content in FTND score has implications for the assessment of tobacco dependence and NRT dose. The study implies validation of FTND using nicotine quantity in the consumed tobacco product as a scorable parameter in the FTND.

Background: Subjective experience means subtle, not yet psychotic abnormalities of experience that might be present during remitted phase and also in prodromal phase of schizophrenia and might be accurately efficient in identifying individuals at risk of eminent psychosis (Parnas et al., 2003). Apart from schizophrenic patients, bipolar patients also experience certain subjective symptoms in their euthymic state. They often experience subtle cognitive impairment and functional disturbances during their euthymic states. These subjective experiences may be related to distorted cognitive functions in these patients. These experiences include a great variety of cognitive dysfunction complaints about attention, perception, memory, thinking, language, movement, and emotion. Objective: To measure the experience of subjective symptoms and compare them between euthymic bipolar and remitted schizophrenia patients. Materials and Methods: Thirty euthymic bipolar patients and 30 remitted schizophrenia patients as per International Classification of Diseases Tenth Revision were selected for the purpose of the study. At first, sociodemographic data were collected. And then, the patients were assessed using the scales; positive and negative syndrome scale, Young Mania Rating Scale, Hamilton Depression Rating Scale, Symptom Checklist-90-Revised, and Frankfurt Complaint Questionnaire-24. Results: Both the groups showed significant differences in terms of subjective symptoms. However, no significant correlation has been found between the objective psychopathology and subjective experience in the two groups. Conclusion: It can be suggested that the patients with schizophrenia show significantly higher subjective experience when compared with the patients of bipolar disorder.

Background: Evidence linking inflammation and depression is marred by several methodological inconsistencies. Further, varying information is present on the role of gender as a potential confounder in this association. Aims: To assess systemic inflammation in drug naοve depression by measuring selected pro-inflammatory (tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and anti-inflammatory cytokines (transforming growth factor-beta [TGF-β]) and comparing them with a matched control group. We also aimed at exploring the differences in these markers between genders. Setting and Design: The study was a cross-sectional one carried out a teaching cum Tertiary Care Hospital. Materials and Methods: We recruited 55 drug naοve cases diagnosed with major depression and compared them for inflammatory markers with a matched apparently healthy control group (n = 42) at baseline. The inflammatory markers were also compared between the genders. Baseline depression and stress levels were assessed using standard measures. Statistical Analysis Used: Mann-Whitney U-test. Results: In comparison with healthy controls, drug naοve depressed individuals demonstrated significantly raised baseline levels of TNF-α and IL-6 (P < 0.001 for both) but no difference in levels of TGF-β (P = 0.433). Neither the baseline depression nor the stress scores correlated with any of the inflammatory markers (P = 0.955 and 0.816 for TNF-α respectively). Males and females were comparable on the levels of markers studied (P = 0.986, 0.415, and 0.430 for TNF-α, IL-6 and TGF-β respectively). Conclusion: There is evidence for higher baseline inflammation in depression prior to starting anti-depressant therapy. Gender does not mediate this observed link between inflammation and depression.

Background: Lithium, which is frequently used in the treatment of mood disorder, can lead to various types of thyroid dysfunctions. Although clinical examination and biochemical assessment are fundamental to any thyroid work-up of lithium-treated patients, assessment findings vary widely depending on the investigator. Ultrasonographic measurement of thyroid volume has, therefore, been performed in lithium treatment populations and found to be a sensitive tool. Aim: We aimed to determine and compare thyroid gland volume using Ultrasonography and laboratory parameters, (thyroid-stimulating hormone [TSH], T3, and T4) in long-term lithium and other mood stabilizers treated patients with mood disorder. Materials and Methods: In this cross-sectional study, we performed ultrasonography examinations and thyroid function test of 30 patients on lithium treatment and 30 patients on other mood stabilizers. Results: The ultrasonographically measured thyroid volume was significantly increased in patients receiving lithium therapy as compared to the patients receiving other mood stabilizers. The total triiodothyronine (T3) was significantly increased with trends toward increased total thyroxine (T4) and decreased TSH in patients receiving lithium therapy as compared to the patients receiving other mood stabilizers. Conclusion: These results highlight the need of including ultrasonographic measurement of thyroid volume as a part of standard thyroid work-up before initiating lithium prophylaxis and during follow-up. Additional studies on the incidence and mechanism of lithium associated hyperthyroidism are needed.

Introduction: Vascular dementia is the second most common form of dementia and is potentially reversible. Small vessel disease (SVD) closely mimics degenerative dementia in view of its sub-acute onset and progressive course. Therefore, unlike large vessel disease, Hachinski Ischemic scale score may not always reflect vascular cognitive decline resulting in diagnostic and therapeutic confusions. Therefore, there is a need for detailed neuropsychological assessment for various cognitive domains for early identification of vascular cognitive decline as it carries a very good long term prognosis for cognitive morbidity, unlike degenerative dementias. Patients and Methods: This prospective study involves thorough domain based neuropsychological assessment of patients with a radiological diagnosis of SVD involving the following parameters-digit forward and backward, category fluency, color trails, stick test, logical memory test, and bender gestalt test. Magnetic resonance imaging scans done using 3-tesla machines and SVD graded using Fazekas visual scale. Results: The mean Hachinskis score was less sensitive for differentiating vascular dementia from degenerative dementia. However, the domain based neuropsychological scores were highly sensitive showing statistically significant impairment in all 6 domains tested and compared with Fazekas 1-3 grades in imaging. Discussion and Conclusion: This study aimed at establishing an early diagnosis of vascular mild cognitive impairment using domain wise neuropsychological testing and correlating it with radiological scores. Hachinskis score is more sensitive for large vessel disease in view of acute onset and step-like progression as against steady progression in SVD. However, domain-wise testing was highly sensitive in identifying early cognitive impairment in patients with SVD, and early therapeutic interventions are highly rewarding.

Background: Dementia is the most devastating cognitive disorder of the elderly and needs extra attention to care. Therefore, this study was conducted to identify the caregiver burden of dementia key caregivers and their Quality of Life (QOL). Materials and Methods: Sample consisted of purposively selected 24 dementia key caregivers fulfilling the inclusion criteria from the in-patient of the Department of Geriatric Mental Health, King George's Medical University, Lucknow, Uttar Pradesh, India. Zarit Burden Interview and World Health Organization QOL-BREF were administered. Mean, standard deviation, t-test, Chi-square with Yate's correction were used to analyze the data. Results: All key caregivers felt mild to moderate level of burden. Gender-wise significant difference was found on burden area of "expectation" (P < 0.05). Mean scores on physical, psychological, social relationship, and environmental QOL were found to be on lower side. A negative correlation was found between burden and QOL. Conclusion: Professional help and supportive psychotherapy can be provided to the key caregivers of dementia patients to reduce their burden, strengthen the coping skill and thus improve their QOL.

Majority of the published studies on suicide deal with identifying the sociodemographic and psychosocial aspects of suicide attempters and those who have completed suicide or to identify the characteristic differences between the two groups. There are very few studies focusing mainly or only on deliberate self harm. Most of these are hospital based studies or in a setting of general hospital psychiatry units. The present study is from Ram Psychiatry Hospital and Institute, a government licensed private psychiatric institute at Madurai, Tamil Nadu. It is a prospective study of individuals with self harm behavior mostly without the intention to kill, attending the psychiatry outpatient department of the hospital for the period of one year (January to December 2014) a total number of 140 cases are registered. Sociodemographic, clinical profiles with Axis I or Axis II diagnosis or otherwise, and the initiating or precipitating cause or mode of self-injury or self-harm are studied. The results are presented and discussed.

Introduction: Neurocysticercosis (NCC) is the most common parasitic infection of man. In addition to a headache, seizures, and focal deficits, this is associated with significant cognitive dysfunction. Many studies revealed that the number and location of lesions are not always responsible for cognitive dysfunction. Cholinesterase and pseudocholinesterase are found in the walls of the cysticercus which could contribute to cholinergic depletion and thus cognitive dysfunction. Patients and Methods: A total of 43 patients who presented with NCC were evaluated for cognitive deficits, as well as cholinesterase levels in cerebrospinal fluid (CSF) with control CSF from patients undergoing spinal anesthesia. Blood levels of interleukin-10 and tumor necrosis factor alpha were also estimated and correlated with cognitive deficits. Results: There is a mild increase in the acetylcholinesterase in CSF of patients compared to controls, but it did not correlate with cognitive deficits. There is an increase in interleukins to a significant level which correlates with vesicular stage of the organism and cognitive impairment. The number of lesions also correlated with cognitive impairment even though the location did not. The domains of cognitive deficits seen are sustained attention, category fluency, verbal working memory, planning, set shifting, verbal learning, visual memory, and construction. Discussion and Conclusion: NCC is associated with multi-domain cognitive impairment correlates with vescicular stage, proinflammatory cytokines and number of lesions but not location, vesicular stage, and proinflammatory cytokines.

Marchiafava - Bignami disease is rare sequelae of chronic alcohol use. We present a case with transient ischemic attack like presentation and its management with parenteral thiamine. A 53 year old male with history of country liquor use since 32 years was brought to hospital with acute onset of delirium & mild weakness involving motor functions of left side of the body, non-reactive planters and exaggerated tendon reflexes on left side. The MRI showed bilateral hyper intense signal on T2W and FLAIR images & Hypo intense lesion on T1W images involving body, genu and splenium of corpus callosum. The features are suggestive of Marchiafava - Bignami Disease. There have been few guidelines for management of MBD and literature supports use of parenteral thiamine 500mg leading to remission of symptoms and symptomatic improvement. It is advisable to use parenteral thiamine in all cases as it overlaps management of other co-morbidities of chronic alcoholism.

Video game addiction and life style changes: Implications for caregivers burden

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Manoj Kumar SharmaDOI:10.4103/0253-7176.178811

Limitation of available information on caregiver perspective on managing the users excessive use of technology. The present case series explore the caregiver burden related to users addictive use of video game. The users and caregivers approached the service of healthy use of technology (SHUT clinic) for management. They were assessed using Griffith criteria for video game; General Health questionnaire and family burden interview schedule. It demonstrate the addictive use of video game and its impact on users life style and the presence of psychiatric distress/family burden in the caregivers. Caregivers also reported presence of disturbance in psychosocial domains and helplessness to manage the excessive use. It has implications for building support group and service to handle parents' distress and enabling them to handle the dysfunction in users.

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a newly recognised autoimmune condition. With its typical clinical pattern, consistent association with the presence of auto antibodies and rapid improvement with immunotherapy, this condition is giving insights into the boundaries between psychiatry and other neurosciences, and is opening avenues for future research. In a young lady who presented with catatonia, we considered anti-NMDA receptor encephalitis, after ruling out other aetiologies. After a positive antibody test we treated her with immunotherapy. She showed gradual improvement in her psychotic and catatonic symptoms. Knowledge regarding the nature and function of NMDA receptors and pathophysiology of this particular encephalitis is important for psychiatric practice. The great opportunity for research in this area due to its association with psychotic disorders is evident but an appeal to temper the enthusiasm by considering the historical lessons learnt from Karl Jaspers' critique of General Paresis of Insane, is in place. Catatonic syndrome has to be conceptualised broadly and should be recognised with a separate nosological position.

Fahr's disease (FD) is a rare idiopathic degenerative neurological disorder, which can be present in different heterogeneous manifestations and characterized by bilateral symmetrical cerebral calcification. We present a case of a 55-year-old male who presented with the psychotic feature, bilateral tremors of hand and bilateral symmetrical calcification of basal ganglia. Hence our case suggests that psychiatrists should evaluate the cases of psychosis thoroughly when the age of presentation is atypical, and they should consider the diagnosis of FD when psychosis presents with motor abnormalities.

The presentation of Obsessive Compulsive Disorder (OCD) is sometimes unusual and can mimic other disorders. There are a number of rare and varied manifestations of this disorder, reported in literature. The case reported here, presented with a hitherto unreported symptom; a dance-like compulsion in a case of OCD. This symptom is notable for the influence of cultural environment, on the content of symptom manifestation, in a psychiatric disorder. When one symptom in a disorder presents itself very prominently, the other symptoms, which are less prominent become masked; and need to be elicited by detailed assessment.

Dissociative fugue is rare entity to encounter with possible differentials of epilepsy and malingering. It is one of the dissociative disorders rarely seen in clinical practice more often because of the short lasting nature of this condition. This might also be because of organized travel of the individuals during the episodes and return to their families after the recovery from episodes. This is a case description of a patient who has experienced total three episodes of dissociative fugue. The patient has presented during the third episode and two prior episodes were diagnosed as fugue episodes retrospectively based on the history. Planned travel in this case by the patient to a distant location was prevented because of early diagnosis and constant vigilance till the recovery. As in this case, it may be more likely that persons with Dissociative fugue may develop similar episodes if they encounter exceptional perceived stress. However, such conclusions may require follow-up studies.

Movement disorders are known to occur during alcohol withdrawal. Tremor, choreoathetosis, transient parkinsonism, myoclonus and dystonia have been previously described. The present report describes involuntary 'fluttering' movements of fingers developing during alcohol withdrawal reminiscent of a rare form of tardive dyskinesia. Such a presentation has not been described earlier.